Partnerships among Professionals and Families with Young Children: - PowerPoint PPT Presentation

Partnerships among Professionals and Families with Young Children: Caring for the Whole Child Bergen Nelson, MD UCLA Department of Pediatrics Association of Child Development Specialists May 15, 2016

Agenda • 9:30 Introductions • 9:45 Group Brainstorm • 10:00-11:00 Research Examples • 11:00-11:15 Break • 11:15-11:45 Discussion • 12:00 Close

Objectives • Review a bio-psycho-social framework for child health and development • Understand the impacts of key risk and protective factors in early childhood • Articulate strategies and resources to support professionals, children and families

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Determinants of Health • Health care services contribute only about 10% to health (morbidity, life expectancy) Shroeder S, NEJM 2007

Social Determinants From: www.healthypeople.gov

Health  Education Adverse Childhood Education Health Experiences (ACEs) Early Childhood Development Parents and Professionals

Spheres of Influence: What Can We Do? • What can professionals • What can parents do to do to support child support child health heath and and development? development? • Communities? • Health care providers? • Policy-makers? • Early childhood educators? • What can we do in • Social support programs partnership with one and providers? another?

Schools  Health  Education Preconception and prenatal health; Maternal education Adolescent Healthy babies, health, substance healthy use prevention, development; reproductive school readiness health, graduation Children ready to Prevention learn in school; and health Attendance and promotion in school function schools 11

Research Project 1: Developing Tiered Approaches to Identify Young Children with Developmental Risks

Tiered model of risk in 0-5 year-olds Developmental delay: Formal intervention services 5-10% 3 IDEA Parts B and C High risk: Major risk factors, significant parental 2 concerns, delays below 25-30% formal intervention threshold Low risk: Screening and surveillance, parent support, high quality 1 60-70% preventive services

Examples of Tiered Approaches • Response to Intervention (RtI, also called Recognition and Response in early childhood) • Positive Behavior Intervention Support (PBIS) • Center on the Social and Emotional Foundations of Early Learning (CSEFEL) • Tier 1  prevention, screening • Tier 2  targeted initial therapies • Tier 3  high-level, intensive, referrals

Preliminary Study ACADEMIC PEDIATRICS 2013;13:145 – 151

British Birth Cohort Study 1970 Average Position in Distribution Feinstein L. Inequality in the Early Cognitive Development of British Children in the 1970 Cohort. Economica 2003;70:73-97

Aim #1 To develop, using nationally representative early childhood longitudinal data, a clinically useful model that predicts, among 2 year-old children without overt developmental delay, downstream poor school readiness due to low cognitive performance and/or problem behaviors at school entry (ages 5-6 years).

Hypothesis #1 • Among children without overt developmental delay at age 2 years, a discrete set of child- and family-level variables will predict poor school readiness at kindergarten entry.

Methods • Early Childhood Longitudinal Survey- Birth Cohort (ECLS-B) • Nationally-representative sample of >10,000 children, data collections at 9 months, 2 years, 3 to 4 years and at kindergarten entry • Direct assessments of child development, parent and teacher reports

Analyses Outcome  School Readiness at Kindergarten Entry • Poor school readiness = Low scores on either math OR language test; OR High problem behavior scores

Analyses Tier 3  *Presumed eligible for early intervention services at age 2: >1.5 SD below mean on either cognitive OR motor developmental scale; OR > 1 SD below mean on cognitive AND motor; OR Birth weight ≤ 1500 grams *Rosenberg SA, Zhang D, Robinson CC. Prevalence of Developmental Delays and Participation in Early Intervention Services for Young Children. Pediatrics. 2008; 121(6):e1503-1509.

Sample Adequate School Readiness (Tier 1) Analytic N = 3450 Sample Sample with assessments N = 4800 Poor School at both 2yo Readiness and Excluded: (Tier 2) kindergarten likely N = 1350 entry wave eligible for EI (Tier 3) N = 6250 N = 1450

Weighted Proportions 3 = 12% 2 = 24% 1 = 64%

Results: Low Academic Scores Predictor Adjusted Odds 95% Confidence Ratio Interval Child doesn’t combine words 1.7 1.25-2.31 Parent’s expectation for child’s highest education is 1.3 1.04-1.66 < 4-year degree Highest level of parental education: (≥ Bachelor’s degree is reference) Some college 1.8 1.29-2.58 High school diploma or equivalent 3.3 2.34-4.50 Less than high school diploma 5.4 3.62-8.10 Parent health status is fair or poor 1.6 1.14-2.15 Household income is < 185% of FPL 1.4 1.11-1.82 Frequency of shared reading at home: (Every day is reference) 3-6 times per week 1.4 1.01-1.81 1-2 times per week 1.6 1.18-2.09 Not at all 2.1 1.27-3.58 Family has food insecurity 1.6 1.12-2.34 Family history of Learning Disability 1.6 1.23-2.11 Parent rates quality of house as good, fair or poor for raising children (vs. very good or excellent) 1.4 1.14-1.80

Results: High Problem Behaviors Adjusted Odds Ratio Predictor 95% Confidence Interval Male gender 1.8 1.38-2.44 Highest level of parental education: (≥ Bachelor’s degree is reference) Some college 1.4 1.04-1.93 High school diploma or equivalent 1.9 1.33-2.67 Less than high school diploma 1.5 0.97-2.30 Parent health status is fair or poor 1.8 1.21-2.60 Single-parent household 1.5 1.17-2.02 Parental depression 1.4 1.02-2.05 Parental smoking 1.8 1.42-2.38 Frequency of shared reading at home: (Every day is reference) 3-6 times per week 0.9 0.65-1.26 1-2 times per week 1.1 0.78-1.60 Not at all 1.7 1.07-2.85 Family has food insecurity 1.6 1.07-2.50 Parent rates neighborhood as fairly or very unsafe (vs. fairly or very safe) 2.0 1.38-2.76

Maslow’s Hierarchy of Needs

Sensitivity and Specificity of Prediction Models Low Academic Scores High Problem Behaviors Sensitivity Specificity Cut-off Sensitivity Specificity Cut-off Proportion Proportion score positive score positive .60 .79 37 0.28 .60 .72 27 0.32 .70 .67 30 0.40 .70 .60 22 0.41 .80 .56 24 0.49 .80 .46 16 0.57 Areas Under the Curve (AUC): Academic model: 0.76 Behavior model: 0.71 2yo Bayley: 0.66

Next Steps • What are “care bundles” for children at different tiers? • Translate risk stratification and care bundles into a feasible clinical decision support (CDS) tool: Systematic literature review and expert panel process to 1) determine potentially effective interventions for Tier 2 children Develop and test CDS tool, incorporated into an electronic 2) health record, with clinical partners, community advisory board and stakeholder input, and informatics support

Research Project 2: Clinical-Community Partnerships and 2-1-1 Technology to Improve Early Childhood Developmental Screening and Care 29

Trabajando Juntos por Nuestros Niños (Working Together for Our Kids)

Background: Developmental Screening is a Recommended Preventive Service The American Academy of Pediatrics (AAP) recommends universal screening and surveillance: • Ask about and document family concerns at every well visit • Use a validated screening tool at 9, 18 and 24-30 months • Use an autism-specific screening tool at 18 and 24-30 months • Refer promptly to evaluation and intervention services when concerns are detected AAP Council on Children with Disabilities. Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics. 2006;118 (1):405-420. 31

Adverse Childhood Education Health Experiences (ACEs) Early Childhood Development Education Improved Early Early Developmental Developmental, Social, Detection Intervention Screening Educational and Health Outcomes ?

Background: Early Brain Development Source: Center on the Developing Child at Harvard University; http://developingchild.harvard.edu/ 34

Developmental Screening in Pediatrics Need for Quality Improvement: • Despite AAP recommendations, many families’ needs are not met in the child health services system. • ~30-50% of parents with young children report having had a developmental assessment in primary care (Halfon, et al., 2004; Guerrero, et al., 2010). • Many parents would like more guidance from their children’s health providers about learning, development and behavior. • 30-40% of parents with young children have concerns • 4-5% of children ages 0-5 have a written intervention plan • Many children with problems are identified too late, and this is worse for low-income and racial/ethnic minority families. 35

Developmental Screening in Pediatrics Barriers to screening in clinical settings: • Lack of time • Limited training in development and behavior • Lack of familiarity with screening tools • Perceived lack of referral resources • Challenges to follow-up 36